Presentation on theme: "Real Time Abstraction A Multidisciplinary Approach"— Presentation transcript:
1Real Time Abstraction A Multidisciplinary Approach
2Multidisciplinary Team Clinical Care Excellence TeamNurse ManagerStaff NurseCharge NurseAbstractors/CodersPharmacySocial Worker/Utilization ReviewRespiratoryQuality Risk ManagerAdmission Nurse/ Infection ControlSurgical Team MemberRegistration/Insurance Verifier
3Admission Nurse Role Patient Placement/Eligibility Completes Initial InterviewComplete skin assessmentReview all Present on Admission concernsInitiate the CMS indicators when appropriateNote and communicate risk for HACReview all admissions completed on the off shifts for proper documentationMedication reconciliation at AdmissionCompletes Admission worksheet and reports CMS indicator issues to staff nurseReport admitting diagnosis to codersFax admission checklist to Medical Record
4Charge Nurse Role Attend daily Multidisciplinary Meeting at 10:00am Report on tentative discharge dates.Monitor Staff Nurse documentation for CMS compliance.Ensure follow through by staff nurses of items presented at Multidisciplinary Meeting.Staff nurse to report pending issues to charge nurse .Communicates if needed with physicians to ensure compliance with CMS indicators.Reviews daily census reports with History and daily vitals of all patients on floor.Maintains White message board in break room daily
5Staff Nurse Clinical Time with patient Reports on patient to Multidisciplinary team at 10:00am.Clinical documentationReview Admission Nurse Checklist and follow-up on pending issues that have been identified.Obtains physician orders to comply with CMS indicators using standing orders or evidence based order sets.Views message board-post-it in EMR for issues from abstractor. Place action taken with date and time.Follows up on actions needed from message board in EMR on documentation required and or seeks physician orders to comply with CMS indicators.Rounds on patient
6AbstractorsDaily review of inpatients EMR and surgical schedule and ensure compliance with CMS Indicators.Attend daily Multidisciplinary meeting at 10:00 and report and follow-up on pending documentation issues.Comment in EMR on message board –Post-it documentation issues.Report any significant changes in care plan or diagnosis to coders and multidisplinary team.outstanding issues to nursing supervisor/charge.
7CoderAssign a working DRG at admission based on admitting diagnosis and history and physical.Attend Multidisciplinary Meetings, present preliminary coding of cases to abstractors.Post changes to DRG through review of chart or through communication with abstractor in EMR through Post-it.
8PharmacistMedication Reconciliation Review at Admission, transfers and dischargeAttend Multidisciplinary MeetingsCommunicate medication changes with physicians that are needed to meet CMS indicator medication requirements.
9Social Worker/ Utilization Review Social Issues and PlacementAttend all Multidisciplinary MeetingsEnsure documentation of Care Conferences in patient chart.Confirm and communicate insurance data and eligibility.Report Insurance StatusAppropriate use of level of care to ensure best reimbursement.Assign tentative discharge date and relays to team.Help team achieve discharge date
11Admission Checklist from Admission Nurse Program SAM-MC
12COMMUNICATIONCommunication will be the Key to Success
13Communication Standardize communication Use SBAR and standarized taxonomyS- situation; whats the problemB- background; the context, objective data, the numbersAssessment: whats the problem?Recommendation; what do we need to do and when? How are we going to fix it? What is needed from physician
14COMMUNICATION Saves time for physicians, patients and staff Clear way to communicateAvoid staff and physician frustrationEliminate unnecessary information(hear-say, and opinions)
16COMMUNICATIONDisplay results of CMS Indicator Scores and publically reported measures in all break rooms so all staff aware of our standing and update monthly.Continued education on CMS Indicators and future indicators.
18TeamworkEnhance performance and ensure the best quality of care by teamAll of team on same pageNo idea or suggestion discouragedEvery team member has a voiceBrainstorm to achieve best outcome.Administrative support of teamInclude patient concerns
19GoalQuality Care and the best evidence based practices given for our patients.100% Compliance with CMS IndicatorsObtain highest level of reimbursementAchieve above State and National scores on publically reported measures.Patient, Physician, and Staff Satisfaction
20Work In ProgressBi-Weekly CMS Fallout meeting with nursing supervisors/Charge abstractors and quality.Keep identify what is working and not working or barriers to compliance.Hospitalist added to multidisciplinary daily meeting.Hospitalist follow-up with attending on issues identified at meeting.Address fallout's real-time with staffContinue letters to physicians on fallout's.CPOE/EBOS